QA Investigation Results

Pennsylvania Department of Health
BENCHMARK THERAPIES, INC.
Health Inspection Results
BENCHMARK THERAPIES, INC.
Health Inspection Results For:


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Initial Comments:

Based on the findings of an onsite unannounced Medicare recertification survey completed January 29 through January 30, 2018, Benchmark Therapies was found to be in compliance with the requirements of 42 CFR, Part 485.727, Subpart H, Conditions of Participation for Clinics, Rehabilitation Agencies, and Public Health Agencies as Providers of Outpatient Physical Therapy and Speech-Language Pathology Services - Emergency Preparedness.



Plan of Correction:




Initial Comments:


Based on the findings of an onsite unannounced Medicare recertification survey completed January 29 through January 30, 2018, Benchmark Therapies, Inc. was found not to be in compliance with the following requirement of 42 CFR, Part 485, Subpart H, Conditions of Participation for Clinics, Rehabilitation Agencies, and Public Health Agencies as Providers of Outpatient Physical Therapy and Speech-Language Pathology Services.


Plan of Correction:




485.709(a) STANDARD
GOVERNING BODY

Name - Component - 00
There is a governing body (or designated person(s) so functioning) which assumes full legal responsibility for the overall conduct of the clinic or rehabilitation agency and for compliance with applicable law and regulations. The name of the owner(s) of the clinic or rehabilitation agency is fully disclosed to the State agency. In the case of corporations, the names of the corporate officers are made known.





Observations:


Based on review of Department files, facility organizational chart, governing body meeting minutes, and interview with Director of QA (quality assurance) and Administrator, the facility failed to notify the Department of a physical address location and closure of extension sites.

Findings included:

Review on January 29, 2018 at approximately 9:00 a.m. of Department files listed P.O. Box address. No physical address location on file. File listed active extension sites for locations in Erie, Philadelphia, Scranton, Everett, Milesburg, Portage, Pleasant Gap, Pittsburgh, Spring City, Johnstown (two locations), and State College (three locations).

During interview on January 29, 2018 at approximately 12:15 p.m., request made to Director of QA for documentation of organizational structure, list of services provided by agency and staff at all locations. Director of QA stated the facility had treatment areas in two buildings on the campus of the facility with two separate physical addresses. Requested written notification for physical address of the certified entity to be sent to the Department. Documentation was not received by 5:00 p.m.

During interview on January 29, 2018 at approximately 5:10 p.m., when questioned about the Department listing of extension sites, Director of QA stated, "Southeastern Veterans Home [Philadelphia location] moved to another NPI number...maybe two years ago...Spring City...moved to another NPI....with Southeastern...Johnstown [2 sites]...no longer a facility...don't recognize addresses...State College ...all three closed at the beginning of the year..." Director of QA did not know what notifications of changes had been made.

During phone interview on January 30, 2018 at approximately 9:30 a.m., administrator confirmed extension site closures and "change of NPI numbers" occurred and stated "855's were sent" to the Medicare Contractor..."they are slow to approve..." Requested copies of the 855's and approvals. Not received by end of survey.

Organizational chart received January 30, 2018 at approximately 1:00 p.m., and did not identify extension sites or practice locations.
During interview on January 30, 2018 at approximately 1:10 p.m., Area Manager confirmed finding.

Received and reviewed on January 30, 2018 at approximately 12:10 p.m., Governing Body meeting minutes for February 12, 2015, February 12, 2016 and February 10, 2017 did not reveal closures or changes to extension sites.





Plan of Correction:

Benchmark Therapies, Inc. completed the following to correct the current deficiency:
1. Benchmark's Administrator, along with Director of Quality Assurance, updated and corrected the Organizational Chart to include current practice location names, current physical addresses, and current alternate administrators for each location.
2. Benchmark's Governing Body Meeting is scheduled for 2/20/2018. An agenda item has been added for review of current sites, locations, and addresses. The agenda has been completed and distributed for the scheduled meeting. The current Governing Body Meeting Policy has been updated to include necessary items for review that will remain part of the annual agenda for the Governing Body Meeting. Meeting minutes will accurately reflect review and actions taken for current sites, locations, addresses, and organizational structure.
3. Benchmark's Administrator sent a letter on 2/15/2018 to notify Department of the correct physical address of Benchmark's parent site located at 138 Veterans Blvd, Duncansville PA 16635.
4. Benchmark's Administrator sent a letter on 2/15/2018 to notify the Department of the closure of the following extension site locations:
- 1950 Cliffside Drive, State College, PA 16801
- 610 W Whitehall Road, State College, PA 16801
- 2364 Commercial Blvd, State College, PA 16801
- 787 Goucher Street, Johnstown, PA 15905
5. Benchmark's Administrator also sent updated 855 forms to the Medicare Contractor to notify them of the closure of the following extension site locations:
- 1950 Cliffside Drive, State College, PA 16801
- 610 W Whitehall Road, State College, PA 16801
The Medicare Contractor would have been notified of the closure of 2364 Commercial Blvd, State College, PA 16801 and the closure of 787 Goucher St, Johnstown, PA 15905 with the latest Medicare revalidation process.
In order to avoid similar situations and to ensure this problem does not reoccur, Benchmark's Administrator, or designee, will immediately send the necessary notification to the Department and the Medicare Contractor upon closure or change of extension site locations. Benchmark's Director of Quality Assurance, or designee, will review 100% of all submitted letters, CMS 855s, and overall organizational structure every quarter to ensure current practice locations, addresses, and organizational structure accurately reflects current practices. The Governing Body will review 100% of all submitted letters, CMS 855s, and overall organizational structure annually in conjunction with the Governing Body Meeting held annually within the first quarter.



485.709(b) STANDARD
ADMINISTRATOR

Name - Component - 00
The governing body appoints a full time qualified administrator, delegates to the administrator the internal operation of the clinic or rehabilitation agency in accordance with established written policies, defines clearly the administrator's responsibilities for procurement and directions to personnel, and designates a competent individual to act during temporary absence of the administrator.






Observations:


Based on review of Department files, governing body meeting minutes, and organizational chart and interview with QA Director, Area Manager, and Administrator, the administrator failed to maintain evidence for designation of an alternate administrator for three extension sites.

Findings included:

Review on January 29, 2018 at approximately 9:00 a.m. of Department files listed P.O. Box address. No physical address location on file for certified facility. File listed active extension sites for locations in Erie, Philadelphia, Scranton, Everett, Milesburg, Portage, Pleasant Gap, Pittsburgh, Spring City, Johnstown (two locations), and State College (three locations).

During interview on January 29, 2018 at approximately 12:15 p.m., request made to Director of QA for documentation of organizational structure, list of services provided by agency and staff at all locations. Documentation was not received by 5:00 p.m.

During interview on January 29, 2018 at approximately 5:10 p.m., when questioned about the Department listing of extension sites, Director of QA stated, "Southeastern Veterans Home [Philadelphia location] moved to another NPI number...maybe two years ago...Spring City...moved to another NPI....with Southeastern...Johnstown [2 sites]...no longer a facility...don't recognize addresses...State College ...all three closed at the beginning of the year..." Director of QA did not know what notifications of changes had been made.

During phone interview on January 30, 2018 at approximately 9:30 a.m., administrator confirmed extension site closures and "change of NPI numbers" occurred and stated "855's were sent" to the Medicare Contractor..."they are slow to approve..." Administrator, stated, the alternate for the administrator is a qualified therapist at their respective extension sites and documentation of agreement to accept designation was in Governing Body meeting minutes.

Organizational chart received January 30, 2018 at approximately 1:00 p.m., did not identify extension sites or practice locations. List of staff for respective extension sites not received.
During interview on January 30, 2018 at approximately 1:10 p.m., Area Manager confirmed finding.

Received and reviewd on January 30, 2018 at approximately 12:10 p.m., Governing Body meeting minutes for February 12, 2015, February 12, 2016 and February 10, 2017 did not identify extension sites for Pleasant Gap, Scranton, or Everett and did not identify alternate administrator for these respective locations.



Plan of Correction:

Benchmark Therapies Administrator reviewed current site managers at each location. Alternate Administrator letters were reviewed within their personnel files and updated to ensure that all current site managers have been designated as the Alternate with a signed attestation. All current Alternate Administrators at each site will be educated on 2/19/2018 and 2/20/2018 on their duties and responsibilities as the Alternate. In order to avoid similar situations and to ensure this problem does not reoccur, Benchmark's Human Resources will review the current list of Alternate Administrators and ensure that evidence of this designation remains on file for each site. Benchmark's Director of Quality Assurance, or designee, will audit 100% of current site manager personnel files every quarterly for the next year to ensure that there is evidence of designated Alternate Administrators. The Governing Body will audit 100% of current site manager personnel files annually to ensure that there is evidence of designated Alternate Administrators.